Provider Demographics
NPI:1144881947
Name:AVERY-MCDANIEL, ELLEN LYNN (BCABA)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:LYNN
Last Name:AVERY-MCDANIEL
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:578 LEE RD
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:GA
Mailing Address - Zip Code:31321-8329
Mailing Address - Country:US
Mailing Address - Phone:864-325-2530
Mailing Address - Fax:
Practice Address - Street 1:785 KING GEORGE BLVD STE 103
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-8376
Practice Address - Country:US
Practice Address - Phone:931-252-0040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-24
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0-19-9996103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst